Nabh standards 3rd edition highlighted

NABH

1. 1 Components of Standards Development Multiple Information Sources Scientific literature JCI Standards UK Healthcare Quality Standards Thailand Standards AHA Draft Standards JCI Survey compliance data Research Findings Individual input from field experts and key stakeholders ISO 9001-2000

2. 2 Hospital Standards Organized around important functions Focus on patient and staff safety Set standards that all organizations must pass To be revised periodically and raise the “bar” Achieve International recognition

3. 3 NABH Standards 10 Chapters 102 Standards 636 Objective Elements

4. 4 Standards and Objective Elements A standard is a statement that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care Objective element is a measurable component of a standard Acceptable compliance with objective elements determines the overall compliance with a standard

5. 5 Section I: Patient-Centered Standards STD OE Access, Assessment and Continuity of Care (AAC) 14 86 Care of Patients (COP) 20 136 Management of Medications (MOM) 13 73 Patient Rights and Education (PRE) 7 46 Hospital Infection Control (HIC) 9 51

6. 6 Section II: Organization Centered Standards STD OE Continuous Quality Improvement (CQI) 8 57 Responsibilities of Management (ROM) 6 38 Facility Management & Safety (FMS) 8 54 Human Resource Management (HRM) 10 52 Information Management Systems (IMS) 7 43 102 636

7. 7 NABH STANDARDS

8. 8 Introduction NABH hospital standards, 3rd edition, 2011 have been prepared by Technical Committee of NABH and contain complete set of standards for evaluation of hospitals for grant of accreditation. The standards provide framework for quality assurance and quality improvement for hospitals NABH Standards contains 10 chapters,102 standards and 628 objective elements.

9. 9 Details of Chapters Access ,Assessment and continuity of care (AAC) Care of Patients (COP). Management of Medication (MOM). Patient Right and Education (PRE). Hospital Infection Control (HIC). Continuous Quality Improvement (CQI). Responsibility of Management (ROM). Facility Management and Safety (FMS). Human Resource Management (HRM) Information Management System (IMS).

10. 10 Chapter 1. ACCESS,ASSESSMENT AND CONTINIUITY OF CARE (AAC)

11. 11 AAC.1 The organization defines and displays the services that it can provide Objective Elements The services being provided are clearly defined and are in consonance with the needs of the community. The defined services are prominently displayed. The staff is oriented to these services.

12. 12 AAC.2 The organization has a well defined registration and admission process Objective elements Documented policies and procedures are used for registering and admitting patients. b) The documented procedures address out- patients, in-patients and emergency patients.

13. 13 Cont… A unique identification number is generated at the end of registration. Patients are accepted only if the organization can provide the required service. The documented policies and procedures also address managing patients during non availability of beds. The staff is aware of these processes.

14. 14 AAC.3 There is an appropriate mechanism for transfer ( in and out) or referral of patients who do not match the organizational resources Objective elements Documented policies and procedures guide the transfer-in of patients to the organization. Documented policies and procedures guide the transfer-out/referral of unstable patients to another facility in an appropriate manner..

15. 15 Cont… Documented policies and procedures guide the transfer-out/referral of stable patients to another facility in an appropriate manner. The documented procedures identify staff responsible during transfer/referral The organization gives a summary of patient’s condition and the treatment given.

16. 16 AAC.4 Patients cared for by the organization undergo an established initial assessment Objective elements The organization defines the content of the assessments for the out–patients, in-patients and emergency patients. The organization determines who can perform the assessments.

17. 17 Cont… The organization defines the time frame within which the initial assessment is completed. The initial assessment for in-patients is documented within 24 hours or earlier as per the patient’s condition or hospital policy. Initial assessment of in-patients includes nursing assessment which is done at the time of admission and documented. Initial assessment includes screening for nutritional needs.

18. 18 Cont… g) The initial assessment results in a documented plan of care h) The plan of care also includes preventive aspects of the care. The plan of care is countersigned by the clinician in-charge of the patient within 24 hours. j) The plan of care includes goals or desired results of the treatment, care or service

19. 19 AAC.5 All patients cared for by the organization undergo a regular reassessment Objective elements. Patients are reassessed at appropriate intervals. Out-patients are informed of their next follow up where appropriate. For in-patients during reassessment the plan of care is monitored and modified where found necessary.

20. Cont.. d) Staff involved in direct clinical care document reassessments. e) Patients are reassessed to determine their response to treatment and to plan further treatment or discharge. 20

21. 21 AAC.6 Laboratory services are provided as per the requirements of the patients Objective elements Scope of the laboratory services are commensurate to the services provided by the organization The infrastructure (physical and manpower) is adequate to provide for its defined scope of services.

22. 22 Cont.. Adequately qualified and trained personnel perform and/or supervise the investigations. Documented procedures guide ordering of tests, collection, identification, handling, safe transportation, processing and disposal of specimens. Laboratory results are available within a defined time frame.

23. Cont.. f) Critical results are intimated immediately to the concerned personnel. g) Results are reported in a standardized manner. h) Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system. 23

24. 24 AAC.7 There is an established laboratory quality assurance programme Objective elements The laboratory quality assurance programme is documented. The programme addresses verification and validation of test methods. The programme addresses surveillance of test results.

25. 25 Cont… The programme includes periodic calibration and maintenance of all equipments. The programme includes the documentation of corrective and preventive actions

26. 26 AAC.8 There is an established laboratory safety programme Objective elements. The laboratory safety programme is documented. This programme is aligned with the organization’s safety programme .

27. 27 Cont… Written policies and procedures guide the handling and disposal of infectious and hazardous materials. d) Laboratory personnel are appropriately trained in safe practices. e) Laboratory personnel are provided with appropriate safety equipment / devices.

28. 28 AAC.9 Imaging services are provided as per the requirements of the patients Objective elements Imaging services comply with legal and other requirements. Scope of the imaging services are commensurate to the services provided by the organization. The infrastructure (physical and manpower) is adequate to provide for its defined scope of services.

29. 29 Cont… Adequately qualified and trained personnel perform, supervise and interpret the investigations. Policies and procedures guide identification and safe transportation of patients to imaging services. Imaging results are available within a defined time frame. Critical results are intimated immediately to the concerned personnel.

30. Results are reported in a standardized manner. Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system. 30

31. 31 AAC.10 There is an established Quality assurance programme for imaging services Objective elements The quality assurance programme for imaging services is documented. The programme addresses verification and validation of imaging methods The programme addresses surveillance of imaging results

32. 32 cont… The programme includes periodic calibration and maintenance of all equipments. The programme includes the documentation of corrective and preventive actions

33. 33 AAC.11 There is an established radiation safety programme Objective elements The radiation safety programme is documented. This programme is aligned with the organization’s safety programme . Handling, usage and disposal of radio-active and hazardous materials is as per statutory requirements.

34. 34 Cont… Imaging personnel are provided with appropriate radiation safety devices Radiation safety devices are periodically tested and documented. Imaging personnel are trained in radiation safety measures. Imaging signage are prominently displayed in all appropriate locations.

35. 35 AAC.12 Patient care is continuous and multidisciplinary in nature Objective elements During all phases of care, there is a qualified individual identified as responsible for the patient’s care. Care of patients is coordinated in all care settings within the organization.

36. 36 Cont… Information about the patient’s care and response to treatment is shared among medical, nursing and other care providers. Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments. Transfers between departments/units are done in a safe manner. The patient’s record (s) is available to the authorized care providers to facilitate the exchange of information. Documented procedures guide the referral of patients to other department / specialties.

37. 37 AAC.13 The organization has a documented discharge process Objective elements The patient’s discharge process is planned in consultation with the patient and/or family. b) Documented procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases and absconded cases )

38. 38 Cont… Documented policies and procedures are in place for patients leaving against medical advice and patients being discharged on request. A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice and on request ).

39. 39 AAC.14 Organisation defines the content of the discharge summary Objective elements Discharge summary is provided to the patients at the time of discharge Discharge summary contains the patient’s name, unique identification number, date of admission and date of discharge. Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge.

40. 40 Cont… d) Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given. e) Discharge summary contains follow up advice, medication and other instructions in an understandable manner.

41. 41 Cont… f) Discharge summary incorporates instructions about when and how to obtain urgent care g) In case of death the summary of the case also includes the cause of death.

42. 42 Chapter 2. Care of Patients (COP)

43. 43 COP.1 Uniform care of patients is provided in all settings of the organization guided by the applicable laws and regulations Objective elements Care delivery is uniform when similar care is provided in more than one setting Uniform care is guided by documented policies and procedures

44. 44 Cont… These reflect applicable laws, regulations and guidelines The organization adapts evidence based medicine and clinical practice guidelines to guide uniform patient care.

45. 45 COP.2 Emergency services are guided by documented policies, procedures, applicable laws and regulations Objective elements Policies and procedure for emergency care are documented and are in consonance with statutory requirements. This also address handling of medico-legal cases The patients receive care in consonance with the policies

46. 46 Cont… Documented policies and procedures guide the triage of patients for initiation of appropriate care Staff is familiar with the policies and trained on the procedures for care of emergency patients Admission or discharge to home or transfer to another organization is also documented In case of discharge to home or transfer to another organization a discharge note shall be given to the patient.

47. 47 COP.3 The ambulance services are commensurate with the scope of the services provided by the organization Objective elements There is adequate access and space for the ambulance(s) The ambulance adheres to statutory requirements. Ambulance(s) is appropriately equipped Ambulance(s) is manned by trained personnel

48. 48 Cont… e) There is a checklist of all equipment and emergency medications f) Equipment are checked on a daily basis g) Emergency medications are checked daily and prior to dispatch h) The ambulance(s) has a proper communication system

49. 49 COP.4 Documented p olicies and procedures guide the care of patients requiring cardio-pulmonary resuscitation Objective elements Documented policies and procedures guide the uniform use of resuscitation throughout the organization Staff providing direct patient care is trained and periodically updated in cardio pulmonary resuscitation

50. 50 Cont… The events during a cardio-pulmonary resuscitation are recorded d) A post event analysis of all cardiac arrests is done by a multidisciplinary committee. e) Corrective and preventive measures are taken based on the post-event analysis.

51. COP.5: Documented policies and procedures guide nursing care. Objective elements There are documented policies and procedures for all activities of the Nursing Services. These reflect current standards of nursing services and practice, relevant regulations and the purposes of the services. Assignment of patient care is done as per current good practice guidelines. 51

52. Cont… d) Nursing care is aligned and integrated with overall patient care. e) Care provided by nurses is documented in the patient record f) Nurses are provided with adequate equipment for providing safe and efficient nursing services. g) Nurses are empowered to take nursing related decisions to ensure timely care of patients. 52

53. COP.6: Documented procedures guide the performance of various procedures . Objective elements   Documented procedures are used to guide the performance of various clinical procedures. b) Only qualified personnel order, plan, perform and assist in performing procedures. c) Documented procedures exist to prevent adverse events like wrong site, wrong patient and wrong procedure.   53

54. Cont… d ) Informed consent is taken by the personnel performing the procedure where applicable.   e) Adherence to standard precautions and asepsis is adhered to during the conduct of the procedure. Patients are appropriately monitored during and after the procedure. g) Procedures are documented accurately in the patient record. 54

55. 55 COP.7 Policies and procedures define rational use of blood and blood products Objective elements Documented policies and procedures are used to guide rational use of blood and blood products Documented procedures govern transfusion of blood and blood products

56. 56 Cont… The transfusion services are governed by the applicable laws and regulations. Informed consent is obtained for donation and transfusion of blood and blood products. Informed consent also includes patient and family education about donation. The organization defines the process for availability and transfusion of blood/blood components for use in emergency. Post transfusion form is collected; reactions if any identified and are analysed for preventive and corrective actions. Staff is trained to implement the policies

57. 57 COP.8 Policies and procedures guide the care of patients in the Intensive care and high dependency units Objective elements Documented policies and procedures are used to guide the care of patients in the intensive care and high dependency units. The organization has documented admission and discharge criteria for its intensive care and high dependency units Staff is trained to apply these criteria

58. 58 Cont… d) Adequate staff and equipment are available e ) Defined procedures for situation of bed shortages are followed f) Infection control practices are followed g) A quality assurance program is implemented

59. 59 COP.9 Documented p olicies and procedures guide the care of vulnerable patients (elderly, children, physically and/or mentally challenged) Objective elements Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines

60. 60 Cont… Care is organized and delivered in accordance with the policies and procedures The organization provides for a safe and secure environment for this vulnerable group A documented procedure exists for obtaining informed consent from the appropriate legal representative. Staff is trained to care for this vulnerable group.

61. 61 COP.10 Policies and procedures guide the care of high risk obstetrical patients Objective elements. There is a documented policy and procedure for obstetric services. The organization defines and displays whether high risk obstetric cases can be cared for or not Persons caring for high risk obstetric cases are competent

62. 62 Cont… d) Documented procedures guide provision of ante-natal services. e) Obstetric patient’s assessment also includes maternal nutrition. f) Appropriate pre-natal, peri -natal and post-natal monitoring is performed and documented. g) The organization caring for high risk obstetric cases has the facilities to take care of neonates of such cases.

63. 63 COP.11 Documented policies and procedures guide the care of pediatric patients Objective elements . There is a documented policy and procedure for paediatric services . The organization defines and displays the scope of its pediatric services The policy for care of neonatal patients is in consonance with the national/ international guidelines Those who care for children have age specific competency

64. 64 Cont… e) Provisions are made for special care of children f) Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment g) Documented policies and procedures prevent child/ neonate abduction and abuse

65. 65 cont… h) The children’s family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record

66. 66 COP.12   Policies and procedures guide the care of patients undergoing moderate sedation Objective elements Documented procedures guide the administration of moderate sedation. Informed consent for administration of moderate sedation is obtained. Competent and trained persons perform sedation The person administering and monitoring sedation is different from the person performing the procedure

67. 67 Cont… e) Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and level of sedation Patients are monitored after sedation Criteria are used to determine appropriateness of discharge from the recovery area h) Equipment and manpower are available to rescue patients from a deeper level of sedation than that intended

68. 68 COP.13 Documented p olicies and procedures guide the administration of anesthesia Objective elements There is a documented policy and procedure for the administration of anesthesia Patients for anaesthesia have a pre- anaesthesia assessment by a qualified anaesthesiologist .

69. 69 Cont… The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented d) An immediate preoperative reevaluation is documented e) Informed consent for administration of anesthesia is obtained by the anesthetist f) During anesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and end tidal carbon dioxide.

70. 70 Cont… Each patient’s post-anesthesia status is monitored and documented The anaesthesiologist applies defined criteria to transfer the patient from the recovery area The type of anaesthesia and anaesthetic medications used are documented in the patient record. Procedures shall comply with infection control guidelines to prevent cross infection between patients. Adverse anesthesia events are recorded and monitored

71. 71 COP.14 Documented p olicies and procedures guide the care of patients undergoing surgical procedures Objective elements The policies and procedures are documented Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery

72. 72 Cont… An informed consent is obtained by a surgeon prior to the procedure Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery Persons qualified by law are permitted to perform the procedures that they are entitled to perform An operative note is documented prior to transfer out of patient from recovery area

73. 73 Cont… The operating surgeon documents the post-operative plan of care Patient, personnel and material flow conforms to infection control practices. Appropriate facilities and equipment/appliances/instrumentation are available in the operating theatre.

74. j) A quality assurance program is followed for the surgical services k) The quality assurance program includes surveillance of the operation theatre environment 74

75. 75 COP.15 Documented p olicies and procedures guide the care of patients under restraints (physical and / or chemical) Objective elements. Documented policies and procedures guide the care of patients under restraints These include both physical and chemical restraint measures

76. 76 Cont… These include documentation of reasons for restraints These patients are more frequently monitored Staff receive training and periodic updating in control and restraint techniques

77. 77 COP.16 Policies and procedures guide appropriate pain management Objective elements Documented policies and procedures guide the management of pain All patients are screened for pain. Patients with pain undergo detailed assessment and periodic re-assessment.

78. Cont.. d) The organization respects and supports the appropriate assessment and management of pain for all patients e) Patient and family are educated on various pain management techniques 78

79. 79 COP.17 Documented policies and procedures guide appropriate rehabilitative services Objective elements Documented policies and procedures guide the provision of rehabilitative services These services are commensurate with the organizational requirements Care is guided by functional assessment and periodic re-assessment which is done and documented by qualified individual (s).

80. Cont.. d) Care is provided adhering to infection control and safe practices. e) Rehabilitative services are provided by a multidisciplinary team f) There is adequate space and equipment to perform these activities. 80

81. 81 COP.18 Documented policies and procedures guide all research activities Objective elements. Documented policies and procedures guide all research activities in compliance with national and international guidelines The organization has an ethics committee to oversee all research activities The committee has the powers to discontinue a research trial when risks outweigh the potential benefits

82. 82 Cont… Patient’s informed consent is obtained before entering them in research protocols Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization’s services

83. 83 COP.19 Documented policies and procedures guide nutritional therapy Objective elements Documented policies and procedures guide nutritional assessment and reassessment Patients receive food according to their clinical needs There is a written order for the diet Nutritional therapy is planned and provided in a collaborative manner

84. 84 Cont… When families provide food, they are educated about the patients diet limitations Food is prepared, handled, stored and distributed in a safe manner

85. 85 COP.20 Documented p olicies and procedures guide the end of life care Objective elements Documented policies and procedures guide the end of life care These policies and procedures are in consonance with the legal requirements These also address the identification of the unique needs of such patient and family.

86. 86 Cont… d) Symptomatic treatment is provided and where appropriate measures are taken for alleviation of pain. e) Staff is educated and trained in end of life care

87. 87 Chapter 3. MANAGEMENT OF MEDICATION (MOM)

88. 88 MOM.1 Documented policies and procedures guide the organization of pharmacy services and usage of medication Objective elements There is a documented policy and procedure for pharmacy services and medication usage These comply with the applicable laws and regulations

89. 89 Cont… A multidisciplinary committee guides the formulation and implementation of these policies and procedures There is a procedure to obtain medication when the pharmacy is closed.

90. 90 MOM.2 There is a hospital formulary Objective elements A list of medication appropriate for the patients and organization’s resources is developed The list is developed collaboratively by the multidisciplinary committee The formulary is available for clinicians to refer and adhere to. There is a defined process for acquisition of these medications There is a process to obtain medications not listed in the formulary

91. 91 MOM.3 Documented policies and procedures guide the storage of medication Objective elements Documented policies and procedures exist for storage of medication Medications are stored in a clean; safe and secure environment; and incorporating manufacturer’s recommendation (s). Sound inventory control practices guide storage of the medications

92. 92 Cont… Sound alike and look alike medications are stored separately The list of emergency medications is defined and is stored in a uniform manner Emergency medications are available all the time Emergency medications are replenished in a timely manner when used

93. 93 MOM.4 Documented policies and procedures guide the safe and rational prescription of medications Objective elements Documented policies and procedures exist for prescription of medications These incorporate inclusion of good practices/guidelines for rational prescription of medications. The organization determines the minimum requirements of a prescription.

94. 94 Cont… Known drug allergies are ascertained before prescribing. The organization determines who can write orders Orders are written in a uniform location in the medical records Medication orders are clear, legible, dated, timed, named and signed Medication orders contain the name of the medicine, route of administration, dose to be administered and frequency/time of administration .

95. Cont.. Documented policy and procedure on verbal orders is implemented. j) T he organization defines a list of high risk medication k) Audit of medication orders/prescription is carried out to check for safe and rational prescription of medications. l) Corrective and/or preventive action (s) is taken based on the analysis where appropriate. 95

96. 96 MOM.5 Documented policies and procedures guide the safe dispensing of medications Objective elements Documented policies and procedures guide the safe dispensing of medications The procedure addresses medication recall Expiry dates are checked prior to dispensing There is a procedure for near expiry medications.

97. Cont.. e) Labeling requirements are documented and implemented by the organization f) High risk medication orders are verified prior to dispensing. 97

98. 98 MOM.6 There are documented policies and procedures for medication administration Objective elements Medications are administered by those who are permitted by law to do so Prepared medication are labeled prior to preparation of a second drug Patient is identified prior to administration

99. 99 Cont… Medication is verified from the order prior to administration Dosage is verified from the order prior to administration Route is verified from the order prior to administration Timing is verified from the order prior to administration

100. 100 Cont… Medication administration is documented i ) Documented polices and procedures govern patient’s self administration of medications j) Documented polices and procedures govern patient’s medications brought from outside the organization

101. 101 MOM.7 Patients are monitored after medication administration. Objective elements Documented policies and procedures guide the monitoring of patients after medication administration. The organization defines those situations where close monitoring is required. Monitoring is done in a collaborative manner. Medications are changed where appropriate based on the monitoring.

102. 102 MOM.8 Near misses, medication errors and adverse drug events are reported and analysed. Objective elements Documented procedure exists to capture near miss, medication error and adverse drug event. Near miss, medication error and adverse drug event are defined. These are reported within a specified time frame.

103. 103 Cont… These are collected and analysed . e) Corrective and/or preventive action (s) is taken based on the analysis where appropriate.

104. 104 MOM.9 Documented procedures guide the use of narcotic drugs and psychotropic substances Objective elements Documented policies and procedures guide the use of narcotic drugs and psychotropic substances These drugs are stored in a secure manner. These policies are in consonance with local and national regulations

105. 105 Cont… d) A proper record is kept of the usage, administration and disposal of these drugs e) These drugs are handled by appropriate personnel in accordance with policies

106. 106 MOM.10 Documented policies and procedures guide the usage of chemotherapeutic agents Objective elements Documented policies and procedures guide the usage of chemotherapeutic agents Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy

107. 107 Cont… Chemotherapy is prepared and administered by qualified personnel Chemotherapy drugs are disposed off in accordance with legal requirements

108. 108 MOM.11 Documented policies and procedures govern usage of radioactive drugs Objective elements. Documented policies and procedures govern usage of radioactive drugs These policies and procedures are in consonance with laws and regulations

109. 109 Cont… The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs Staff, patients and visitors are educated on safety precautions

110. 110 MOM.12 Documented policies and procedures guide the use of implantable prosthesis Objective elements. Usage of implantable prosthesis and medical devices is guided by scientific criteria for each individual item and national / international recognized guidelines / approvals for such specific item(s). Documented policies and procedures govern procurement, storage / stocking, issuance and usage of implantable prosthesis and medical devices incorporating manufacturer’s recommendation(s).*

111. 111 cont… Patient and his / her family are counselled for the usage of implantable prosthesis and medical device including precautions, if any. The batch and serial number of the implantable prosthesis are recorded in the patient’s medical record and the master logbook

112. 112 MOM.13 Documented policies and procedures guide the use of medical supplies and consumables Objective elements There is a defined process for acquisition of medical supplies and consumables. Medical supplies and consumables are used in a safe manner where appropriate.

113. 113 Cont… Medical supplies and consumables are stored in a clean; safe and secure environment; and incorporating manufacturer’s recommendation (s). d) Sound inventory control practices guide storage of medical supplies and consumables.

114. 114 Chapter. 4 PATIENT RIGHT AND EDUCATION (PRE)

115. 115 PRE.1 The organization protects patient and family rights informs them about their responsibilities during care Objective element Patient and family rights and responsibilities are documented. Patients and families are informed of their rights and responsibilities in a format and language that they can understand

116. 116 Cont… The organization’s leaders protect patient’s rights Staff is aware of their responsibility in protecting patients rights Violation of patient rights is recorded, reviewed and corrective/preventive measures taken

117. 117 PR E .2. Patient and family rights support individual beliefs, values and involve the patient and family in decision making processes Objective elements a ) Patient and family rights address any special preferences, spiritual and cultural needs . b) Patient rights include respect for personal dignity and privacy during examination, procedures and treatment

118. 118 Cont… Patient rights include protection from physical abuse or neglect Patient rights include treating patient information as confidential Patient rights include refusal of treatment Patient and family rights include informed consent before transfusion of blood and blood products, anaesthesia, surgery, initiation of any research protocol and any other invasive / high risk procedures / treatment.

119. 119 Cont… g) Patient rights include information on how to voice a complaint h) Patient rights include information on the expected cost of the treatment Patient has a right to have an access to his / her clinical records j) Patient and family rights include information on plan of care, progress and information on their health care needs.

120. PRE.3: The patient and/ or family members are educated to make informed decisions and are involved in the care planning and delivery process. Objective elements The patient and/or family members are explained about the proposed care including the risks, alternatives and benefits. The patient and/or family members are explained about the expected results. The patient and / or family members are explained about the possible complications. 120

121. Cont.. d) The care plan is prepared and modified in consultation with patient and/or family members. e) The care plan respects and where possible incorporates patient and/or family concerns and requests. f) The patient and/or family members are informed about the results of diagnostic tests and the diagnosis g) The patient and/or family members are explained about any change in the patient’s condition. 121

122. 122 PR E .4 A documented procedure for obtaining patient and / or families consent exists for informed decision making about their care Objective elements Documented procedure incorporates the list of situations where informed consent is required and the process for taking informed consent.

123. 123 Cont… General consent for treatment is obtained when the patient enters the organization Patient and/or his family members are informed of the scope of such general consent Informed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand The policy describes who can give consent when patient is incapable of independents decision making.

124. Cont.. f) Informed consent is taken by the person performing the procedure. Informed consent process adheres to statutory norms. h) Staff are aware of the informed consent procedure. 124

125. 125 PRE.5 Patient and families have a right to information and education about their healthcare needs Objective elements Patient and/or family are educated about the safe and effective use of medication and the potential side effects of the medication, when appropriate. Patient and/or family are educated about food-drug interactions.

126. 126 Cont… Patient and/or family are educated about diet and nutrition. Patient and families are educated about immunizations Patient and/or family are educated about organ donation, when appropriate. Patient and families are educated about their specific disease process, complications and prevention strategies

127. Cont.. g) Patient and families are educated about preventing infections h) Patients are taught in a language and format that they can understand 127

128. 128 PRE.6. Patient and families have a right to information on expected costs Objective elements There is uniform pricing policy in a given setting (out-patient and ward category) The tariff list is available to patients Patients are educated about the estimated costs of treatment

129. 129 Cont… Patients and family are informed about the financial implications when there is a change in the patient condition or treatment setting

130. PRE.7: Organization has a complaint redressal procedure. Objective elements a ) The organization has a documented complaint redressal procedure. b) Patient and/or family members are made aware of the procedure for lodging complaints. c) All complaints are analysed . d) Corrective and/or preventive action (s) is taken based on the analysis where appropriate . 130

131. 131 Chapter 5 HOSPITAL INFECTION CONTROL (HIC)

132. 132 HIC.1 The organization has a well-designed, comprehensive and coordinated Hospital Infection Control (HIC) programme aimed at reducing/ eliminating risks to patients, visitors and providers of care.

133. 133 Objective elements The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections. The infection prevention and control programme is a continuous process and updated at least once in a year. The hospital has a multi-disciplinary infection control committee which co-ordinates all infection prevention and control activities.

134. Cont… d) The hospital has an infection control team which co-ordinates implementation of all infection prevention and control activities. e) The hospital has designated infection control officer as part of the infection control team. f) The hospital has designated and qualified infection control nurse(s) for this activity 134

135. 135 HIC.2 : The organization implements the policies and procedures laid down in the Infection Control Manual. Objective elements The organization identifies the various high-risk areas and procedures and implements policies and/or procedures to prevent infection in these areas . The organization adheres to standard precautions at all times.

136. 136 Cont… The organization adheres to hand hygiene guidelines. The organization adheres to safe injection and infusion practices. The organization adheres to transmission based precautions at all times. The organization adheres to cleaning, disinfection and sterilization practices An appropriate antibiotic policy is established and implemented.

137. h) Laundry and linen management processes are also included. The organization adheres to kitchen sanitation and food handling issues. j) The organization has appropriate engineering controls to prevent infections. k) The organization adheres to housekeeping procedures. 137

138. 138 HIC.3 The organization performs surveillance activities to capture and monitor infection prevention and control data . Objective elements Surveillance activities are appropriately directed towards the identified high-risk areas. Collection of surveillance data is an ongoing process.

139. 139 Cont… Verification of data is done on regular basis by the infection control team. Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends. Surveillance activities include monitoring the compliance with hand hygiene guidelines. Surveillance activities include monitoring the effectiveness of housekeeping services.

140. Cont… g ) Appropriate feedback regarding HAI rates are provided on a regular basis to appropriate personnel. h) In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities. 140

141. 141 HIC.4: The organization takes actions to prevent and control Healthcare Associated Infections (HAI) in patients. Objective elements The organization monitors urinary tract infections. The organization monitors respiratory tract infections.

142. 142 Cont… The organization monitors intra-vascular device infections. The organization monitors surgical site infections.

143. 143 HIC.5 The organization provides adequate and appropriate resources for prevention and control of Healthcare Associated Infections (HAI). Objective elements Adequate and appropriate personal protective equipment, soaps, and disinfectants are available and used correctly. Adequate and appropriate facilities for hand hygiene in all patient care areas are accessible to health care providers.

144. 144 Cont… Isolation/ barrier nursing facilities are available. Appropriate pre and post exposure prophylaxis is provided to all concerned staff members.

145. 145 HIC.6 The organization identifies and takes appropriate action to control outbreaks of infections. Objective elements Organization has a documented procedure for identifying an outbreak. Organization has a documented procedure for handling such outbreaks. This procedure is implemented during outbreaks. After the outbreak is over appropriate corrective actions are taken to prevent recurrence

146. 146 HIC.7 There are documented policies and procedures for sterilisation activities in the hospital . Objective elements The organization provides adequate space and appropriate zoning for sterilization activities. Documented procedure guides the cleaning, packing, disinfection and/or sterilization, storing and issue of items. Reprocessing of instruments and equipment are covered .

147. d) Regular validation tests for sterilisation are carried out and documented. e) There is an established recall procedure when breakdown in the sterilisation system is identified 147

148. 148 HIC.8 Biomedical waste (BMW) is handled in an appropriate and safe manner. Objective elements The organization adheres to statutory provisions with regard to biomedical waste . Proper segregation and collection of Bio-medical Waste from all patient care areas of the hospital is implemented and monitored.

149. 149 Cont… The organization ensures that Bio-medical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner. Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorised contractor(s). Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste

150. 150 HIC.9 The infection control programme is supported by the organization’s management and includes training of staff. Objective elements Hospital management makes available resources required for the infection control programme The hospital regularly earmarks adequate funds from its annual budget in this regard.

151. 151 Cont… It conducts regular pre-induction training for appropriate categories of staff before joining concerned department(s). It also conducts regular “in-service” training sessions for all concerned categories of staff at least once in a year.

152. 152 Chapter 6 CONTINUOUS QUALITY IMPROVEMENT (CQI)

153. 153 CQI.1 There is a structured quality improvement and continuous monitoring programme in the organization Objective elements The quality improvement programme is developed, implemented and maintained by a multi-disciplinary committee. The quality improvement programme is documented.

154. 154 Cont… There is a designated individual for coordinating and implementing the quality improvement programme The quality improvement programme is comprehensive and covers all the major elements related to quality assurance and risk management.

155. 155 Cont… The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism. The quality improvement programme is reviewed at predefined intervals and opportunities for improvement are identified. The quality improvement programme is a continuous process and updated at least once in a year

156. Cont.. h) Audits are conducted at regular intervals as a means of continuous monitoring. i ) There is an established process in the organization to monitor and improve quality of nursing and complete patient care . 156

157. CQI.2: There is a structured patient safety programme in the organization. Objective elements The patient safety programme is developed, implemented and maintained by a multi-disciplinary committee. The patient safety programme is documented. The patient safety programme is comprehensive and covers all the major elements related to patient safety and risk management. 157

158. Cont.. d) The scope of the programme is defined to include adverse events ranging from “no harm” to “sentinel events”. e) There is a designated individual for coordinating and implementing the patient safety programme . f) The designated programme is communicated and coordinated amongst all the staff of the organization through appropriate training mechanism. . 158

159. Cont.. g) The patient safety programme identifies opportunities for improvement based on review at pre-defined intervals. h) The patient safety programme is a continuous process and updated at least once in a year i )The organization adapts and implements national/international patient safety goals/solutions. j) The organization uses at least two identifiers to identify patients across the organization. 159

160. 160 CQI.3 The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as tools for continual improvement . Objective elements Monitoring includes appropriate patient assessment. Monitoring includes safety and quality control programme of the diagnostics services. Monitoring includes medication management. .

161. 161 Cont… Monitoring includes use of anaesthesia. Monitoring includes surgical services. Monitoring includes use of blood and blood products. Monitoring includes infection control activities. Monitoring includes review of mortality and morbidity indicators. Monitoring includes clinical research.

162. 162 Cont. j) Monitoring includes data collection to support further improvements. k) Monitoring includes data collection to support evaluation of these improvements.

163. 163 CQI.4 The organisation identifies key indicators to monitor the managerial structures, processes and outcomes which are used as tools for continual improvement Objective elements a) Monitoring includes procurement of medication essential to meet patient needs. b) Monitoring includes risk management.

164. 164 Cont… c) Monitoring includes utilisation of space, manpower and equipment. d) Monitoring includes patient satisfaction which also incorporates waiting time for services. e) Monitoring includes employee satisfaction. f) Monitoring includes adverse events and near misses. g) Monitoring includes availability and content of medical records.

165. 165 Cont.. h) Monitoring includes data collection to support further study for improvements. i ) Monitoring includes data collection to support evaluation of the improvements

166. 166 CQI.5 The quality improvement programme is supported by the management Objective elements The management makes available adequate resources required for quality improvement programme. Organization earmarks adequate funds from its annual budget in this regard. The management identifies organizational performance improvement targets.

167. d) The management supports and implements use of appropriate quality improvement, statistical and management tools in its quality improvement programme 167

168. 168 CQI.6 There is an established system for clinical audit Objective elements Medical and nursing staff participates in this system. The parameters to be audited are defined by the organisation. Patient and staff anonymity is maintained. All audits are documented. Remedial measures are implemented.

169. CQI.7: Incidents, complaints and feedback are collected and analysed to ensure continual quality improvement . Objective elements The organization has an incident reporting system. The organization has a process to collect feedback and receive complaints. The organization has established processes for analysis of incidents, feedbacks and complaints. 169

170. d) Corrective and preventive actions are taken based on the findings of such analysis. e) Feedback about care and service is communicated to staff. 170

171. 171 CQI.8 Sentinel events are intensively analysed Objective elements The organisation has defined sentinel events. The organisation has established processes for intense analysis of such events. Sentinel events are intensively analysed when they occur. Corrective and Preventive Actions are taken based on the findings of such analysis.

172. 172 Chapter 7 RESPONSIBILITIES OF MANAGEMENT (ROM)

173. 173 ROM.1 The responsibilities of those responsible for management are defined Objective elements Those responsible for governance lay down the organization’s mission statement. Those responsible for governance lay down the strategic and operational plans commensurate to the organization's mission in consultation with the various stake holders . 

174. 174 Cont… c) Those responsible for governance monitor and measure the performance of the organization against the stated mission. d) Those responsible for governance establish the organization’s organogram . e) Those responsible for governance appoint the senior leaders in the organization. f) Those responsible for governance support safety initiatives and quality improvement plans.

175. 175 Cont… g) Those responsible for governance support research activities. h) Those responsible for governance address the organization’s social responsibility i ) Those responsible for governance inform the public of the quality and performance of services.

176. ROM.2: The organization complies with the laid down and applicable legislations and regulations. Objective elements The management is conversant with the laws and regulations and knows their applicability to the organization. The management ensures implementation of these requirements. 176

177. Cont.. c) Management regularly updates any amendments in the prevailing laws of the land. d ) There is a mechanism to regularly update licenses/ registrations/certifications. 177

178. 178 ROM.3 The services provided by each department are documented Objective elements Scope of services of each department is defined Administrative policies and procedures for each department are maintained. Each organizational programme , service, site or department has effective leadership. Departmental leaders are involved in quality improvement

179. 179 ROM.4 The organization is managed by the leaders in an ethical manner Objective elements The leaders make public the mission statement of the organization. The leaders establish the organization’s ethical management. The organization discloses its ownership.

180. 180 Cont… The organization honestly portrays the services which it can and cannot provide. The organization honestly portrays its affiliations and accreditations. The organization accurately bills for it’s services based upon a standard billing tariff.

181. 181 ROM.5: The organization displays professionalism in management of affairs. Objective elements The person heading the organization has requisite and appropriate administrative qualifications. b) The person heading the organization has requisite and appropriate administrative experience.

182. 182 Cont… c) The organization prepares the strategic and operational plans including long term and short term goals commensurate to the organization’s vision, mission and values in consultation with the various stake holders. d) The organization coordinates the functioning with departments and external agencies, and monitors the progress in achieving the defined goals and objectives. e) The organization plans and budgets for its activities annually.

183. Cont… f The performance of the senior leaders is reviewed for their effectiveness. g) The functioning of committees is reviewed for their effectiveness. h) The organization documents employee rights and responsibilities. The organization documents the service standards. j) The organization has a formal documented agreement for all outsourced services. k) The organization monitors the quality of the outsourced services. 183

184. 184 ROM.6: Management ensures that patient safety aspects and risk management issues are an integral part of patient care and hospital management. Objective elements Management ensures proactive risk management across the organization. Management provides resources for proactive risk assessment and risk reduction activities.

185. Cont.. c) Management ensures implementation of systems for internal and external reporting of system and process failures. d) Management ensures that appropriate corrective and preventive action is taken to address safety related incidents. 185

186. 186 Chapter 8 FACILITY MANAGEMENT AND SAFETY (FMS)

187. 187 FMS.1: The organization has a system in place to provide a safe and secure environment. Objective elements Safety committee coordinates development, implementation, and monitoring of the safety plan and policies Patient safety devices are installed across the organization and inspected periodically. The organization is a non-smoking area.

188. 188 Cont… Facility inspection rounds to ensure safety are conducted at least twice in a year in patient care areas and at least once in a year in non-patient care areas. Inspection reports are documented and corrective and preventive measures are undertaken. There is a safety education programme for staff.

189. 189 FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors. Objective elements Facilities are appropriate to the scope of services of the organization. . Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes

190. 190 Cont… There is internal and external sign posting in the organization in a language understood by patients, families and community. The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies. Potable water and electricity are available round the clock.

191. 191 Cont… f) Alternate sources for electricity and water are provided as backup for any failure / shortage. g) The organization regularly tests these alternate sources . h) There are designated individuals responsible for the maintenance of all the facilities. There is a documented operational and maintenance (preventive and breakdown) plan.

192. Cont…. j) Maintenance staff is contactable round the clock for emergency repairs. k) Response times are monitored from reporting to inspection and implementation of corrective actions. 192

193. 193 FMS.3: The organization has a programme for engineering support services. Objective elements The organization plans for equipment in accordance with its services and strategic plan Equipment are selected, rented, updated or upgraded by a collaborative process. Equipment are inventoried and proper logs are maintained as required.  

194. 194 Cont… Qualified and trained personnel operate and maintain the equipment. There is a documented operational and maintenance (preventive and breakdown) plan. There is a maintenance plan for water management. There is a maintenance plan for electrical systems.

195. Cont… h) There is a maintenance plan for heating, ventilation and air-conditioning. i ) There is a documented procedure for equipment replacement and disposal. 195

196. 196 FMS.4: The organization has a programme for bio-medical equipment management. Objective elements The organization plans for equipment in accordance with its services and strategic plan. Equipment are selected, rented, updated or upgraded by a collaborative process. Equipment are inventoried and proper logs are maintained as required.  

197. 197 Cont.. d) Qualified and trained personnel operate and maintain the medical equipment. e) Equipment are periodically inspected and calibrated for their proper functioning. f) There is a documented operational and maintenance (preventive and breakdown) plan. g) There is a documented procedure for equipment replacement and disposal.*

198. FMS.5: The organization has a programme for medical gases, vacuum and compressed air. Objective elements a) Documented procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases. b) Medical gases are handled, stored, distributed and used in a safe manner. c) The procedures for medical gases address the safety issues at all levels. 198

199. d) Alternate sources for medical gases, vacuum and compressed air are provided for, in case of failure. e) The organization regularly tests these alternate sources. f) There is an operational and maintenance plan for piped medical gas, compressed air and vacuum installation.* 199

200. 200 FMS.6 The organization has plans for fire and non-fire emergencies within the facilities Objective elements The organization has plans and provisions for early detection, containment and abatement of fire and non-fire emergencies.

201. 201 Cont… The organization has a documented safe exit plan in case of fire and non-fire emergencies. Staff is trained for their role in case of such emergencies. Mock drills are held at least twice in a year There is a maintenance plan for fire related equipment.

202. 202 FMS.7 The organization plans for handling community emergencies, epidemics and other disasters Objective elements The hospital identifies potential emergencies. The organization has a documented disaster management plan.

203. 203 Cont… Provision is made for availability of medical supplies, equipment and materials during such emergencies. Hospital staff is trained in the hospital’s disaster management plan The plan is tested at least twice in a year.

204. 204 FMS.8 The organization has a plan for management of hazardous materials Objective elements Hazardous materials are identified within the organization The hospital implements processes for sorting, labelling, handling, storage, transporting and disposal of hazardous material.

205. 205 Cont… Requisite regulatory requirements are met in respect of radioactive materials. There is a plan for managing spills of hazardous materials Staff is educated and trained for handling such materials.

206. 206 Chapter 9 HUMAN RESOURCE MANAGEMENT

207. 207 HRM.1 The organization has a documented system of human resource planning Objective elements Human resource planning supports the organization’s current and future ability to meet the care, treatment and service needs of the patient. The organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient .

208. 208 Cont… c) The required job specifications and job description are well defined for each category of staff. d) The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.

209. 209 HRM.2. The organization has a documented procedure for recruiting staff and orienting them to the organization’s environment. Objective elements There is a documented procedure for recruitment. Recruitment is based on pre-defined criteria. Every staff member entering the organization is provided induction training The induction training includes orientation to the organization’s vision, mission and values.

210. 210 Cont… e) The induction training includes awareness on employee rights and responsibilities. f) The induction training includes awareness on patient’s rights and responsibilities. g) The induction training includes orientation to the service standards of the organization. h ) Each staff member is made aware of hospital wide policies and procedures as well as relevant department / unit / service / programme’s policies and procedures.

211. 211 HRM.3 There is an ongoing programme for professional training and development of the staff Objective elements A documented training and development policy exists for the staff. The organization maintains the training record. Training also occurs when job responsibilities change/ new equipment is introduced. Feedback mechanisms for assessment of training and development programme exist.

212. 212 HRM.4 Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety Objective elements All staff is trained on the risks within the hospital environment. Staff members can demonstrate and take actions to report, eliminate / minimize risks.

213. 213 Cont… Staff members are made aware of procedures to follow in the event of an incident. d) Staff are trained on occupational safety aspects.

214. 214 HRM.5 An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process Objective elements A well-documented performance appraisal system exists in the organization . The employees are made aware of the system of appraisal at the time of induction

215. 215 Cont… c ) Performance is evaluated based on the performance expectations described in job description. The appraisal system is used as a tool for further development. Performance appraisal is carried out at pre defined intervals and is documented .

216. 216 HRM.6 The organization has a well-documented disciplinary and grievance handling policies and procedures. Objective elements Documented policies and procedures exist. The policies and procedures are known to all categories of staff of the organization. The disciplinary policy and procedure is based on the principles of natural justice.

217. 217 Cont… d) The disciplinary procedure is in consonance with the prevailing laws. e) There is a provision for appeals in all disciplinary cases. f) The redress procedure addresses the grievance. g) Actions are taken to redress the grievance.

218. 218 HRM.7 The organization addresses the health needs of the employees Objective elements A pre-employment medical examination is conducted on all the employees. Health problems of the employees are taken care of in accordance with the organization’s policy.

219. 219 Cont… Regular physical and medical checks are done at-least once a year and the findings/ results are documented. Occupational health hazards are adequately addressed.

220. 220 HRM.8 There is documented personal information for each staff member. Objective elements Personal files are maintained in respect of all employees. The personal files contain personal information regarding the employees qualification, disciplinary background and health status

221. 221 Cont… All records of in-service training and education are contained in the personal files. Personal files contain results of all evaluations

222. 222 HRM.9 There is a process for credentialing and privileging of medical professionals, permitted to provide patient care without supervision.

223. 223 Objective elements Medical professionals permitted by law, regulation and the hospital to provide patient care without supervision is identified. The education, registration, training and experience of the identified medical professionals is documented and updated periodically. All such information pertaining to the medical professionals is appropriately verified when possible. 

224. Cont… d) Medical professionals are granted privileges to admit and care for patients in consonance with their qualification, training, experience and registration. e) The requisite services to be provided by the medical professionals are known to them as well as the various departments / units of the organization. f) Medical professionals admit and care for patients as per their privileging. 224

225. 225 HRM.10 There is a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision.

226. 226 Objective elements Nursing staff permitted by law, regulation and the organization to provide patient care without supervision are identified. The education, registration, training and experience of nursing staff is documented and updated periodically. All such information pertaining to the nursing staff is appropriately verified when possible. Nursing staff are granted privileges in consonance with their qualification, training, experience and registration.

227. Cont... e) The requisite services to be provided by the nursing staff are known to them as well as the various departments / units of the organization. f) Nursing professionals care for patients as per their privileging. 227

228. 228 Chapter.10 INFORMATION MANAGEMENT SYSTEM (IMS)

229. 229 IMS.1 Documented policies and procedures exist to meet the information needs of the care providers, management of the organization as well as other agencies that require data and information from the organization

230. 230 Objective elements The information needs of the organization are identified and are appropriate to the scope of the services being provided by the organization and the complexity of the organization Documented policies and procedures to meet the information needs are documented. These policies and procedures are in compliance with the prevailing laws and regulations.

231. 231 Cont… All information management and technology acquisitions are in accordance with the policies and procedures. The organization contributes to external databases in accordance with the law and regulations

232. 232 IMS.2 The organization has processes in place for effective management of data Objective elements Formats for data collection are standardized Necessary resources are available for analyzing data Documented procedures are laid down for timely and accurate dissemination of data

233. 233 Cont… Documented procedures exist for storing and retrieving data Appropriate clinical and managerial staff participates in selecting, integrating and using data.

234. 234 IMS.3 The organization has a complete and accurate medical record for every patient Objective elements Every medical record has a unique identifier. Organization policy identifies those authorized to make entries in medical record.

235. 235 Cont… Every medical record entry is dated and timed. The author of the entry can be identified The contents of medical record are identified and documented The record provides an up-to-date and chronological account of patient care Provision is made for 24-hour availability of the patient’s record to healthcare providers to ensure continuity of care.

236. 236 IMS.4 The medical record reflects continuity of care Objective elements The medical record contains information regarding reasons for admission, diagnosis and plan of care. The medical record contains the results of tests carried out and the care provided . Operative and other procedures performed are incorporated in the medical record

237. 237 Cont… d) When patient is transferred to another hospital, the medical record contains the date of transfer, the reason for the transfer and the name of the receiving hospital e) The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel

238. 238 Cont… f) In case of death, the medical record contains a copy of the death certificate indicating the cause, date and time of death. g) Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same. h) Care providers have access to current and past medical record.

239. 239 IMS.5 Documented policies and procedures are in place for maintaining confidentiality, integrity and security of information Objective elements Documented policies and procedures exist for maintaining confidentiality, security and integrity of information

240. 240 Cont… Documented policies and procedures are in consonance with the applicable laws The policies and procedures incorporate safeguarding of data/ record against loss, destruction and tampering The hospital has an effective process of monitoring compliance of the laid down policy

241. 241 Cont… The hospital uses developments in appropriate technology for improving, confidentiality, integrity and security Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization

242. 242 Cont… A documented procedure exists on how to respond to patients / physicians and other public agencies requests for access to information in the clinical record in accordance with the local and national law.

243. 243 IMS.6 Documented policies and procedures exist for retention time of records, data and information Objective elements Documented policies and procedures are in place on retaining the patient’s clinical records, data and information The policies and procedures are in consonance with the local and national laws and regulations

244. 244 Cont… The retention process provides expected confidentiality and security The destruction of medical records, data and information is in accordance with the laid down policy

245. 245 IMS.7 The organization regularly carries out review of medical records Objective elements The medical records are reviewed periodically The review uses a representative sample based on statistical principles. The review is conducted by identified care providers.

246. 246 Cont… The review focuses on the timeliness, legibility and completeness of the medical records The review process includes records of both active and discharged patients The review points out and documents any deficiencies in records Appropriate corrective and preventive measures undertaken are documented.

247. 247 Thank you